An Unusual Dog Bite in an Infant with Penetrating Brain Injury and Scalp Loss.
The most life-threatening bites fall in Grade III as per Rueff classification of animal bite. Because infants have a larger head size as compared to the rest of the body, they are very commonly injured on scalp. We report a rare clinical presentation of dog bite on scalp in a 5-month-old child where there was near total loss of scalp with protrusion of brain matter from a fractured skull. The brain bulge warns direct contamination with dog's saliva along with suspected neurological deficient. We stress on the need of neurological evaluation, adequate resuscitation, antirabies immunoglobulins, antibiotics, and required wound coverage in such cases to decrease the chances of intracranial infections.
A 5-month-old infant boy was brought to the emergency department along with his mother and elder brother, all being inflicted by bites from neighbor's dog. Although the elder brother and mother sustained only scratches, the dog dragged the infant's head from his mother's lap, while she was self-defensive and caused him severe injuries on his scalp. He had near total loss of scalp in vertex area measuring 10 cm x 12 cm with loss of periosteum, fractured and raised parietal bone with dural tear and brain matter bulge [Figure 1]. The infant was crying on admission, and there was no reported loss of consciousness or seizures or any other neurological symptoms. He was actively moving his four limbs. He was referred from a hospital at 500 km and looked pale and hypovolemic. His hemoglobin was reported to be 6 g%. On computed tomography (CT) scan, there was a fracture of the left parietal bone with brain excursion from the raised fractured bone defect measuring 2 cm x 2 cm. The infant was started with blood transfusion. The wound was thoroughly washed with normal saline, and anti-rabies immunoglobulins were infiltrated in the wound margins and the plane of avulsion of scalp. Antirabies vaccine was started, and the monitoring of dog was asked for. He was put on wide spectrum cephalosporins. The child resuscitation was then continued in pediatric Intensive Care Unit. After stabilization, he was taken up for surgery under general anesthesia on the next day. On exploration, the neurosurgery team found 2 cm x 1.75 cm dural defect in the left high parietal area near to superior sagittal sinus with brain bulge. After the evacuation of the contused brain, they repaired the dural tear with pericranial fascia. A 2 cm x 2 cm bone defect with exposed periosteum was covered with transposition flap from occipital area of scalp (based on superficial temporal and retroauricular artery) [Figure 2]. The thinness of skin and loose areolar tissue in infants, made this flap raising quite challenging. The flap was sutured partially to the margins of the wound for monitoring of any infection. The donor area was grafted with split thickness graft from the left side thigh.
The graft donor area was dressed with multilayer dressing, and the medial and posterior side of dressing was covered with transparent adhesive film to avoid fecal or urinary contamination. Partial congestion of distal flap was noted intraoperative while suturing the flap, which got relieved with position change (right side of scalp was kept up, to help in venous drainage). To avoid the hassle of suture removal, only catgut suture was used. The infant was kept electively intubated and on ventilator for proper immobilization of flap for next 4 days. His recovery progressed very fine, and he was extubated after grafting of the left over raw areas. No signs of wound infection were seen. The schedule of antirabies vaccine was followed, and the child was discharged on day 15 [Figure 3]. The dog was also reported to be doing fine till that day. No significant complaints were found on fortnightly follow-up visits for the next 3 months. No neurological deficiency or delay in milestones is being report so far.
The parents of the infant have been explained about the need of cranioplasty by the age of 5 years and esthetic hair restoration procedures in later years.
Dog bite over scalp in infants can cause life-threatening complications because thin skull bones cannot withstand the pressure generated.  This risk is prevalent in children till the age of 2 years, as per Wilberger et al.  The age of this infant in case report, being 5 months further supports this ideology. Dog bites are divided into three categories  according to the WHO classification [Table 1] and Rueff et al.  [Table 2]. The present case (falling in category/Grade III) is the first of its kind to be ever reported in literature of dog bites in infants. The uniqueness of this case was a fact that there was a large dural defect with bone loss and brain bulge, which required urgent reconstruction to avoid further damage to brain matter. Ng et al. have suggested a management algorithm for a similar injury in their article on scalp avulsion injury in pediatric dog bites.  We advocate the use of computed tomography in all cases of a dog bite on the scalp to look for intracranial damage, as also advised by Iannelli and Lupi.  Such injuries with exposed and saliva contaminated brain can cause intracranial infections and life-long morbidity or death. We recommend the adequate washing of the wound with saline and infiltrating antirabies immunoglobulins along the wound margins and bed in scalp wound. [7,8] In our case, it was given along wound margins. The possibility of intracranial contamination with rabies virus and other intraoral bacterial species such as staphylococcus, streptococcus, or Pasteurella was very high in this case. Previous reports suggest that intracranial bone fragments, dural tear, and CSF leak increase the chances of brain abscess from 7% to 22% [9,10] in dog bite. Callaham [1,10] reported the decreased incidence of brain abscess if the wound is well debrided. Although few studies suggest a role of antibiotics to be very effective in controlling infection, we believe that antibiotics along with early surgery in the form of debridement and coverage of exposed brain defect play in important role in minimizing complications. There are case reports where human allograft and other skin substitutes along with NPWT have been used, and scalp avulsion has been covered over a period of 4 weeks.  Kuvat et al.  suggested that early complete management is preferred over the older idea of delayed reconstruction. Similar management has been suggested by Iannelli.  In our case, because of exposed brain matter and risk of infections, immediate flap was required. We started broad spectrum third-generation cephalosporins to this infant. Advantages of vancomycin and metronidazole have been reported by other authors.  After adequate debridement of contused brain matter and dural repair by neurosurgeon, this infant's scalp defect was reconstructed with local transposition flap from the occipital area based on superficial temporal artery and retroauricular artery. The rest of the area was left raw to observe for any infection and was skin grafted after 4 days. Local scalp flap is the first choice for scalp defect. Although not esthetically very acceptable (because of graft area alopecia), it is a very robust flap and settles very well. The area of the brain involved is to be carefully examined as the subsequent neurological deficiencies may develop. In our case, we were cautious about the speech and hearing defects as the parietal area is involved. Regular follow-up with is essential to rule out any signs of neural infection, meningitis, or delay in developmental milestones.
Unexpected deep injuries can occur with infant dog bites. We recommend the use of CT head for all scalp injuries and swift surgical interventions along with antibiotic and antirabies prophylaxis for better and infection-free outcomes. Regular follow-up is necessary for early detection of any long-term neurological effects.
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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Sheerin Shah, Hanish Bansal (1), Rajinder K. Mittal, Ashwani K. Chaudhary (1), Sanjeev Uppal, Ramneesh Garg, Soheb Rafique, Jagminder Singh (1)
Departments of Plastic and Reconstructive Surgery and (1) Neurosurgery, Dayanand Medical College and Hospital, Tagore Nagar, Ludhiana, Punjab, India
Address for correspondence: Dr. Sheerin Shah, Dayanand Medical College and Hospital, Ludhiana - 141 012, Punjab, India.
How to cite this article: Shah S, Bansal H, Mittal RK, Chaudhary AK, Uppal S, Garg R, et al. An unusual dog bite in an infant with penetrating brain injury and scalp loss. Turk J Plast Surg 2019;27:30-2.
Table 1: World Health Organization classification of dog bite Category Description Action Category 1 Licking, touching on intact skin None Category 2 Saliva on scratches or abrasions Clean wound on skin without bleeding or Antirabies vaccine nibbling of uncovered skin Category 3 Bites or scratches that penetrate Clean wound skin. Exposure of eyes or Antirabies vaccine mouth to saliva from licks Antirabies immunoglobulin Table 2: Rueff et al. classification on animal bite A classification of the severity of bite wounds, from Rueff et al. Grade I Superficial skin lesion Torn skin Scratched skin Bite canal Crushing injury Grade II Wound extending from the skin to the fascia, muscle, or cartilage Grade III Wound with tissue necrosis or tissue loss
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|Title Annotation:||Case Report|
|Author:||Shah, Sheerin; Bansal, Hanish; Mittal, Rajinder K.; Chaudhary, Ashwani K.; Uppal, Sanjeev; Garg, Ram|
|Publication:||Turkish Journal of Plastic Surgery|
|Date:||Jan 1, 2019|
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